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MRCOG PART 2 SBAs and EMQs

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notes334
EMQ1480
SBA2068
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pre-eclampsie

pre-eclampsie Posted by Najah Ali A.
(a) Eclamptic fit is an obstetric emergency that need swift quick action to avoid associating morbidity and mortality. Each unit should have agreed protocol to manage such emergency. Putting the patient in recovery position left lateral for safety and to avoid aspiration, I will ask my staff to call the most senior obstetrician, anesthetist for help, quick assessment of the patient breathing, secure and maintain the airway , provide a high facial oxygen saturation, check pulse and the blood pressure. Collecting blood for fbc, urea and electrolyte, liver function test, coagulation and save serum. At the same time I will start the loading dose of mgso4 at 4 grams I/v over 5-10 min, following with the loading dose at rate of 1 gram/ hour. As the eclamptic fit is a self limiting, there is an evidence that the mgso4 is the agent of choice for preventing further fit, and associated with less maternal mortality [magpie trial].Intravenous anti hypertensive agent [labetalol, hydralazine] according to the unit protocol and to the availability consider to be the agents of choice, risk of profound hypotension and fetal distress is there with both agent. Further fit can be managed by second dose of mgso4 or by increase the infusion rate 1, 5-2 gram/hour. Further fit Diazepam, Phenitoin should be considering with intubations to protect airway and maintain oxygen supplementation.

(b) As the patient condition is stable transfer the patient to H.D.U under multidisciplinary team care involving consultant obstetrician, anaesthist, neonatologist, hematologist and alert the porter to be around. Continuous monitoring of blood pressure, pulse, oxymetry, respiratory rate, deep tendon reflexes, strict urine in put and out put, for early detection of mgso4 toxicity and to be managed accordingly by stop the infusion or by giving the antidote calcium
gluconate .strict fluid balance is associated with good pregnancy out come, one of recommended regimen is urine out come in the last one hour+30ml of infused fluid; this will reduce the risk of pulmonary edema and the risk of renal failure. Fluid load is best to be monitored by C.V.P. Close assessment and evaluation of the patient according to her symptoms, signs and blood work [hematology and chemistry] every 4-6 hours with consultant review and other related specialty if any complications arise. Assessing the fetal well being by regular CTG, U/S looking for fetal presentation, placental location, AFI, fetal growth and by doing umbilical artery Doppler. Delivery is the definitive treatment .Once he condition is stable the woman and her partner should be counseled by properly trained counselor in conjunction With Neonatologist regarding the need of imminent delivery to avoid such mishap which can be life threatening condition and once the lady is primigravida and remote from her due the delivery almost will be through caesarean section and any method of labor induction is unlikely to succeed. The baby will be premature so administration of corticosteroid as per unit protocol will reduce risk of RSD, IVH, and NND, reduce the NICU duration and it is coast effective with out any significant maternal risk, all the information will be baked with printed written leaflet. If the hospital is unequipped or unable to deal with such gestational age arrangement for inutero transfer where such care can be provided .clear careful documentation of all procedures intervention has been under taken taken, the names of all staff involved in the patient care should be clearly documented, keeping the lady and her family updating at all the time is of paramount importance. Writing an incidental report is a vital as apart of risk management.